@Article{info:doi/10.2196/66167, author="Sanchez-Escudero, Pablo Juan and Aguillon, David and Valencia, Stella and Garcia-Barrera, A. Mauricio and Aguirre-Acevedo, Camilo Daniel and Trujillo, Natalia", title="Digital Ergonomics of NavegApp, a Novel Serious Game for Spatial Cognition Assessment: Content Validity and Usability Study", journal="JMIR Serious Games", year="2025", month="Apr", day="2", volume="13", pages="e66167", keywords="serious games", keywords="spatial cognition", keywords="digital neuropsychology", keywords="Alzheimer disease", keywords="content validity", keywords="usability", abstract="Background: Alzheimer disease (AD) is the leading cause of dementia worldwide. With aging populations and limited access to effective treatments, there is an urgent need for innovative markers to support timely preventive interventions. Emerging evidence highlights spatial cognition (SC) as a valuable source of cognitive markers for AD. This study presents NavegApp, a serious game (SG) designed to assess 3 key components of SC, which show potential as cognitive markers for the early detection of AD. Objective: This study aimed to determine the content validity and usability perception of NavegApp across multiple groups of interest. Methods: A multistep process integrating methodologies from software engineering, psychometrics, and health measurement was implemented to validate the software. Our approach was structured into 3 stages, guided by the software life cycle for health and the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations for evaluating the psychometric quality of health instruments. To assess content validity, a panel of 8 experts evaluated the relevance and representativeness of tasks included in the app. In addition, 212 participants, categorized into 5 groups based on their clinical status and risk level for AD, were recruited to evaluate the app's digital ergonomics and usability at various stages of development. Complementary analyses were performed to identify group differences and to explore the association between task difficulty and user agreeableness. Results: NavegApp was validated as a highly usable tool by both experts and users. The expert panel confirmed that the tasks included in the game were representative (Aiken V=0.96-1.00) and relevant (Aiken V=0.96-1.00) for measuring SC components. Both experts and nonexperts rated NavegApp's digital ergonomics positively, with minimal differences between groups (rrb 0.08-0.29). Differences in usability perceptions were observed among participants with sporadic mild cognitive impairment compared to cognitively healthy individuals (rrb 0.26-0.29). A moderate association was also identified between task difficulty and user agreeableness (Cram{\'e}r V=0.37, 95\% CI 0.28-0.54). Conclusions: NavegApp is a valid and user-friendly SG designed for SC assessment, developed by integrating software engineering and psychometric evaluation methodologies. While the results are promising, further studies are warranted to evaluate its diagnostic accuracy and construct validity. This work outlines a comprehensive framework for SG development in cognitive assessment, emphasizing the importance of incorporating psychometric validity measures from the outset of the design process. ", doi="10.2196/66167", url="https://games.jmir.org/2025/1/e66167" } @Article{info:doi/10.2196/65498, author="Gao, Yanan and Zhang, Jinxi and He, Zhonghui and Zhou, Zhixiong", title="Feasibility and Usability of an Artificial Intelligence---Powered Gamification Intervention for Enhancing Physical Activity Among College Students: Quasi-Experimental Study", journal="JMIR Serious Games", year="2025", month="Mar", day="24", volume="13", pages="e65498", keywords="physical activity", keywords="gamification", keywords="artificial intelligence", keywords="digital health", keywords="digital intervention", keywords="feasibility study", abstract="Background: Physical activity (PA) is vital for physical and mental health, but many college students fail to meet recommended levels. Artificial intelligence (AI)-powered gamification interventions through mobile app have the potential to improve PA levels among Chinese college students. Objective: This study aimed to assess the feasibility and usability of an AI-powered gamification intervention. Methods: A quasi-experimental study spanning 2 months was conducted on a sample of college students aged 18 to 25 years old from 18 universities in Beijing. PA data were recorded using the ShouTi Fitness app, and participant engagement was evaluated through surveys. User satisfaction was gauged through the System Usability Scale, while the intervention's feasibility was assessed through Spearman rank correlation analysis, Mann-Whitney tests, and additional descriptive analyses. Results: As of July 2023, we enrolled 456 college students. In total, 18,073 PA sessions were recorded, with men completing 8068 sessions and women completing 10,055 sessions. The average PA intensity was 7 metabolic equivalent of energy (MET)s per session. Most participants preferred afternoon sessions and favored short-duration sessions, with men averaging 66 seconds per session and women 42 seconds. The System Usability Scale score for the intervention based on app is 65.2. Users responded positively to the integration of AI and gamification elements, including personalized recommendations, action recognition, smart grouping, dynamic management, collaborative, and competition. Specifically, 341 users (75\%) found the AI features very interesting, 365 (80\%) were motivated by the gamification elements, 364 (80\%) reported that the intervention supported their fitness goals, and 365 (80\%) considered the intervention reliable. A significant positive correlation was observed between the duration of individual PA and intervention duration for men ($\rho$=0.510, P<.001), although the correlation was weaker for women ($\rho$=0.258, P=.046). However, the frequency of PA declined after 35 days. Conclusions: This study provides pioneering evidence of the feasibility and usability of the AI-powered gamification intervention. While adherence was successfully demonstrated, further studies or interventions are needed to directly assess the impact on PA levels and focus on optimizing long-term adherence strategies and evaluating health outcomes. ", doi="10.2196/65498", url="https://games.jmir.org/2025/1/e65498" } @Article{info:doi/10.2196/57802, author="Mia, Raihan Md and Ahamed, Iqbal Sheikh and Nemanich, Samuel", title="Gamified mHealth System for Evaluating Upper Limb Motor Performance in Children: Cross-Sectional Feasibility Study", journal="JMIR Serious Games", year="2025", month="Feb", day="28", volume="13", pages="e57802", keywords="mobile health", keywords="mHealth", keywords="digital health", keywords="mobile apps", keywords="smartphones", keywords="iPad", keywords="gamification", keywords="serious games", keywords="digital interventions", keywords="digital technology", keywords="spatiotemporal", keywords="upper limb movement", keywords="motor performance", keywords="motor skills", keywords="pediatrics", keywords="toddler", keywords="children", keywords="youth", abstract="Background: Approximately 17\% of children in the United States have been diagnosed with a developmental or neurological disorder that affects upper limb (UL) movements needed for completing activities of daily living. Gold-standard laboratory assessments of the UL are objective and precise but may not be portable, while clinical assessments can be time-intensive. We developed MoEvGame, a mobile health (mHealth) gamification software system for the iPad, as a potential advanced technology to assess UL motor functions. Objective: This feasibility study examines whether MoEvGame can assess children's whole-limb movement, fine motor skills, manual dexterity, and bimanual coordination. The specific aims were to (1) design and develop novel mHealth gamified software tools to examine theory-driven features of UL movement, (2) analyze spatiotemporal game data with new algorithms and statistical techniques to quantify movement performance as a parameter of speed, accuracy, and precision, and (3) validate assessment methods with healthy participants from schools. Methods: Elementary school children (N=31, median 9.0, IQR 4.0-14.0 years old) participated by playing 5 games. The game tasks were focused on key features of skilled motor control: (1) whole limb reaching, (2) fine motor control and manual dexterity, and (3) bilateral coordination. Spatiotemporal game data were transferred and stored in a cloud-based data management server for further processing and analysis. We applied change point detection (ie, the pruned exact linear time method), signal processing techniques, and other algorithms to calculate movement speed and accuracy from spatiotemporal parameters. Different statistical methods (ie, Pearson correlation, mean, standard deviation, P value, 95\% confidence interval) were used to compare speed-accuracy tradeoffs and evaluate the relationship between age and motor performance. Results: A negative correlation was identified between speed and accuracy in the whole limb movement (r=--0.30 to --0.42). Significant relationships between age and upper limb performance were found: older participants exhibited lower errors with faster completion times compared to younger participants. Significant differences in bimanual coordination were found related to phase synchronization (in-phase congruent [mean 28.85, SD 18.97] vs antiphase congruent [mean 112.64, SD 25.82] and in-phase mirrored [mean 23.78, SD 16.07] vs antiphase mirrored [mean 121.39, SD 28.19]). Moreover, the average speed (revolutions per second) and travel distance (m) of the in-phase mode were significantly higher than those of the antiphase coordination. Conclusions: Results of this feasibility study show that spatiotemporal data captured from the mHealth app can quantify motor performance. Moving beyond traditional assessments, MoEvGame incorporates gamification into ubiquitous and accessible technology as a fast, flexible, and objective tool for UL motor assessment. ", doi="10.2196/57802", url="https://games.jmir.org/2025/1/e57802", url="http://www.ncbi.nlm.nih.gov/pubmed/40053722" } @Article{info:doi/10.2196/56269, author="Whitley, Phoebe and Creasey, Connor and Clarkson, J. Matthew and Thompson, Stephen", title="A Serious Game to Study Reduced Field of View in Keyhole Surgery: Development and Experimental Study", journal="JMIR Serious Games", year="2025", month="Feb", day="11", volume="13", pages="e56269", keywords="keyhole surgery", keywords="laparoscopic surgery", keywords="serious games", keywords="image mosaicking", keywords="field of view", keywords="javascript", keywords="html", keywords="opensource", abstract="Background: During keyhole surgery, the surgeon is required to perform highly demanding tasks while only being able to see part of the patient's anatomy. This limited field of view is widely cited as a key limitation of the procedure, and many computational methods have been proposed to overcome it. However, the precise effects of a limited field of view on task performance remain unknown due to the lack of tools to study these effects effectively. Objective: This paper describes our work on developing a serious game with 2 objectives: (1) to create an engaging game that communicates some of the challenges of keyhole surgery, and (2) to test the effect of a limited field of view on task performance. The development of a serious game that can be played by a wide range of participants will enable us to gather quantitative data on the effects of the reduced field of view on task performance. These data can inform the future development of technologies to help surgeons reduce the impact of a limited field of view on clinical outcomes for patients. The game is open source and may be adapted and used by other researchers to study related problems. Methods: We implemented an open-source serious game in JavaScript, inspired by the surgical task of selectively cauterizing blood vessels during twin-to-twin transfusion surgery. During the game, the player is required to identify and cut the correct blood vessel under different fields of view and varying levels of vascular complexity. We conducted a quantitative analysis of task performance time under different conditions and a formative analysis of the game using participant questionnaires. Results: We recruited 25 players to test the game and recorded their task performance time, accuracy, and qualitative metrics. Reducing the field of view resulted in participants taking significantly longer (P<.001) to perform otherwise identical tasks (mean 6.4 seconds, 95\% CI 5.0-7.8 seconds vs mean 13.6 seconds, 95\% CI 10.3-16.9 seconds). Participants found the game engaging and agreed that it enhanced their understanding of the limited field of view during keyhole surgery. Conclusions: We recruited 25 players to test the game and recorded their task performance time, accuracy, and qualitative metrics. Reducing the field of view resulted in participants taking statistically significantly longer (16.4 vs 9.8 seconds; P=.05) to perform otherwise identical tasks. Participants found the game engaging and agreed that it enhanced their understanding of the limited field of view during keyhole surgery. ", doi="10.2196/56269", url="https://games.jmir.org/2025/1/e56269" } @Article{info:doi/10.2196/53045, author="Su, Kuan-Chu and Wu, Ko-Chiu and Chou, Kuei-Ru and Huang, Chia-Hsu", title="Tongue Muscle Training App for Middle-Aged and Older Adults Incorporating Flow-Based Gameplay: Design and Feasibility Pilot Study", journal="JMIR Serious Games", year="2025", month="Jan", day="9", volume="13", pages="e53045", keywords="exergame", keywords="mobile app", keywords="flow", keywords="self-care", keywords="feasibility", keywords="older adults", keywords="dysphagia", keywords="tongue exercises", abstract="Background: Complications due to dysphagia are increasingly prevalent among older adults; however, the tediousness and complexity of conventional tongue rehabilitation treatments affect their willingness to rehabilitate. It is unclear whether integrating gameplay into a tongue training app is a feasible approach to rehabilitation. Objective: Tongue training has been proven helpful for dysphagia treatment. Following the development of a tongue training app, a feasibility trial aimed to identify physiological and psychological factors that affect user and flow experience and explored whether training specialized muscles could produce a flow experience for optimal immersion. We aimed to provide a useful tool for medical rehabilitation so that older adults could retain tongue muscle flexibility. Methods: After consulting professional nurses, we developed a mobile gaming app for middle-aged and older adults to train their tongue muscles. This pilot study used an image recognition system to detect the tongue movements of 32 healthy middle-aged and older adults (7 males, 21.9\%; 25 females, 78.1\%) during 3 game training tasks, each requiring different reaction speeds. Their physiological and psychological signals, as well as the results of the Flow State Scale 2 (FSS2) questionnaire, were used for correlation analysis regarding relevant flow experiences to establish and evaluate the feasibility of our method. Results: Through exploratory factor analyses, a 2-factor (operation and immersion) structure was confirmed to have an adequate model fit ($\chi${\texttwosuperior}36=448.478; P<.001; Kaiser-Meyer-Olkin=0.757) and internal consistency reliability (Cronbach $\alpha$=0.802). The slow, medium, and fast levels all significantly affected the FSS2 score for operation (P=.001), the National Aeronautics and Space Administration Task Load Index (P<.001), and flow distance (P<.001). K-means clustering revealed that participants could be further categorized into 3 groups. Through the analysis of changes in the participants' physiological and psychological signals for each given task, Pearson correlation indicated that changes were primarily related to flow distance. For the 12 indicators measured in this study, the low, medium, and high operation groups showed significance in 58\% (7/12), 50\% (6/12), and 25\% (3/12) of the indicators, respectively. Similarly, the low, medium, and high immersion groups had changes in 50\% (6/12), 33\% (4/12), and 17\% (2/12) of indicators, respectively. Conclusions: Our research supports the further development of a gaming app to aid older adults with tongue muscle training and measure flow using physiological and psychological signals to enhance training accuracy and feasibility. Next, we aim to conduct a randomized pilot trial, improve app functions, offer alternative rehabilitation options, and encourage long-term participation. Future goals include enhancing long-term efficacy, diversifying training modes, and adding a multiuser interactive option for an added challenge. ", doi="10.2196/53045", url="https://games.jmir.org/2025/1/e53045" } @Article{info:doi/10.2196/57030, author="Samson, Laurent and Carcreff, Lena and Noublanche, Fr{\'e}d{\'e}ric and Noublanche, Sophie and Vermersch-Leiber, H{\'e}l{\`e}ne and Annweiler, C{\'e}dric", title="User Experience of a Semi-Immersive Musical Serious Game to Stimulate Cognitive Functions in Hospitalized Older Patients: Questionnaire Study", journal="JMIR Serious Games", year="2025", month="Jan", day="6", volume="13", pages="e57030", keywords="virtual reality", keywords="geriatrics", keywords="reminiscence", keywords="episodic memory", keywords="serious game", keywords="neurocognitive disorders", keywords="older adults", keywords="user experience", abstract="Background: Reminiscence therapy through music is a psychosocial intervention with benefits for older patients with neurocognitive disorders. Therapies using virtual or augmented reality are efficient in ecologically assessing, and eventually training, episodic memory in older populations. We designed a semi-immersive musical game called ``A Life in Songs,'' which invites patients to immerse themselves in a past era through visuals and songs from that time period. The game aspires to become a playful, easy-to-use, and complete tool for the assessment, rehabilitation, and prevention of neurocognitive decline associated with aging. Objective: This study aimed to assess the user experience (UX) associated with the newly designed serious game. Methods: After one or several sessions of the game guided by the therapist, patients of the geriatric wards were asked to answer questions selected from 2 widely known UX scales (AttrakDiff and meCUE [modular evaluation of the components of user experience]) with the therapist's help. The internal consistency of the UX dimensions was assessed through Cronbach $\alpha$ to verify the validity of the dimensions. The level of engagement of the patient throughout the experimental session was also assessed following an internally developed scale, which included 5 levels (interactive, constructive, active, passive, and disengaged behaviors). UX mean scores were computed and presented graphically. Verbal feedbacks were reported to support the quantitative results. Results: Overall, 60 inpatients with a mean age of 84.2 (SD 5.5) years, the majority of whom were women (41/60, 68\%), were included. Their score on the Mini-Mental State Examination (MMSE) ranged between 12 and 29. A majority of patients (27/56, 48\%) had no major neurocognitive disorder (MNCD), 22/56 (39\%) had mild MNCD, and 7/56 (13\%) had moderate MNCD. The results revealed very positive UX with mean values beyond the neutral values for every UX dimension of both scales. The overall mean (SD) judgment was rated 3.92 (SD 0.87) (on a scale of ?5 to 5). Internal consistency was acceptable to good for the emotional dimensions of the meCUE. Questionable to unacceptable consistency was found for the other UX dimensions. Participants were mostly active (23/60, 38\%) and constructive (21/60, 35\%). Conclusions: These findings demonstrated a very good appreciation of the game by geriatric inpatients. Participants' and health care professionals' verbal comments strongly aligned with the quantitative results. The poor internal consistency in the UX dimensions reflected the high heterogeneity among the included patients. Further studies are needed to evaluate the potential benefits of clinical factors such as neurocognitive functions, mood, depression, or quality of life. ", doi="10.2196/57030", url="https://games.jmir.org/2025/1/e57030" } @Article{info:doi/10.2196/49847, author="Chen, Jiayin and Or, Kalun Calvin and Li, Zhixian and Yeung, Kwong Eric Hiu and Chen, Tianrong", title="Perceptions of Patients With Stroke Regarding an Immersive Virtual Reality--Based Exercise System for Upper Limb Rehabilitation: Questionnaire and Interview Study", journal="JMIR Serious Games", year="2025", month="Jan", day="1", volume="13", pages="e49847", keywords="virtual reality", keywords="stroke", keywords="perception", keywords="rehabilitation", keywords="questionnaire", keywords="interview", abstract="Background: With substantial resources allocated to develop virtual reality (VR)--based rehabilitation exercise programs for poststroke motor rehabilitation, it is important to understand how patients with stroke perceive these technology-driven approaches, as their perceptions can determine acceptance and adherence. Objective: This study aimed to examine the perceptions of patients with stroke regarding an immersive VR-based exercise system developed to deliver shoulder, elbow, forearm, wrist, and reaching exercises. Methods: A questionnaire was used to assess the perceptions of 21 inpatients who had experienced stroke (mean time from stroke onset: 37.2, SD 25.9 days; Brunnstrom stage of stroke recovery for the arm: 3-5) regarding the perceived usefulness of, ease of use of, attitude toward, intrinsic motivation for, and intention to use the exercise system. The measurement items were rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree), with higher values indicating more positive perceptions. Descriptive statistics were used to summarize the responses. Moreover, we conducted semistructured interviews that were audio recorded, transcribed, and subjected to content analysis to identify thematic patterns. Results: The questionnaire results revealed that the patients' perceptions of the exercise system were positive (mean ratings >6). The content analysis revealed 6 positive themes from 73 statements about the exercise system: ease of use, usefulness, enjoyment, motivation, accessibility, and game design. Conversely, 15 statements reflected negative perceptions, which were clustered into 3 themes: difficulty in handling VR devices, uncomfortable experiences when using VR devices, and monotony. Conclusions: Integrating VR technology into poststroke functional exercises holds significant promise based on patient interests. However, patient preferences and adaptability must be considered to promote the technology's success. VR-guided exercises should be user-friendly, health-promoting, engaging, and well-designed. Furthermore, addressing challenges, such as bulkiness, motion sickness, discomfort, and exercise monotony, is crucial for the widespread adoption and diffusion of this technology. ", doi="10.2196/49847", url="https://games.jmir.org/2025/1/e49847" } @Article{info:doi/10.2196/58452, author="Lepe-Salazar, Francisco and Mej{\'i}a-Romero, Fernando and Benicio-Rodr{\'i}guez, D{\'a}maso and Hern{\'a}ndez-Reyes, Aylin and Nakajima, Tatsuo and Salgado-Torres, Sarita", title="Game-Based Promotion of Assertiveness to Mitigate the Effects of Bullying in High School Students: Development and Evaluation Study", journal="JMIR Serious Games", year="2024", month="Dec", day="24", volume="12", pages="e58452", keywords="serious games", keywords="bullying", keywords="assertiveness", keywords="multiple composite scenarios", keywords="scenario", keywords="cognitive behavioral therapy", keywords="gaming", keywords="design", keywords="development", keywords="bully", keywords="assertive", keywords="feasibility", abstract="Background: For years, Mexico has reported the highest global incidence of school bullying, with approximately 19\% of students going through some form of hostile peer interactions. Despite numerous interventions, these harmful conducts remain deeply entrenched in educational environments. Objective: To address this issue, we developed Bernstein, a serious game that promotes assertiveness---an essential protective factor that reduces the negative effects of bullying. Methods: Bernstein was designed using multiple composite scenarios, a methodology grounded in cognitive behavioral therapy. To evaluate the game's effectiveness, we conducted an exploratory trial using the Rathus Assertiveness Schedule to assess assertiveness levels before and after the intervention. Participants were high school students who met the inclusion criteria of being open to playing a serious game (with no prior gaming experience required) and having access to a computer with internet connectivity for remote participation. A total of 100 students (65 boys and 35 girls) enrolled in the intervention; however, only 46 participants in the treatment group and 46 in the control group completed the study, resulting in a dropout rate of 8\% (8/100). A paired 1-tailed t test was used to compare pre- and postintervention scores within each group, and a one-way ANOVA was conducted to compare the average score improvements between the 2 groups. Results: The treatment group showed a pretest mean Rathus Assertiveness Schedule score of --2.78 (SD 25.93) and a posttest mean of 1.69 (SD 29.48), with a paired 1-tailed t test yielding a P value of .01. The control group had a pretest mean of 2.07 (SD 25.69) and a posttest mean of --2.39 (SD 32.98), with a paired 1-tailed t test yielding a P value of .04. The one-way ANOVA (between groups) yielded a P value of .006, indicating a statistically significant difference, favoring Bernstein over the alternative protocol. Participant feedback highlighted the game's engaging narrative and character design, although usability issues, such as navigation challenges, were noted as areas for improvement. Conclusions: The results suggest that Bernstein is a promising tool for promoting assertiveness in high school students, providing a potential strategy for addressing bullying-related issues. The study underscores the value of integrating Bernstein into educational programs, offering students a safe and interactive environment to develop resilience. As an exploratory trial, this study faced limitations affecting the generalizability of findings, including the remote format's impact on facilitator guidance and a relatively small sample size. Further trials with larger, more diverse groups are recommended to validate these early results and enhance Bernstein's scalability as part of a comprehensive antibullying strategy. ", doi="10.2196/58452", url="https://games.jmir.org/2024/1/e58452", url="http://www.ncbi.nlm.nih.gov/pubmed/39718822" } @Article{info:doi/10.2196/60155, author="Kwan, Cho Rick Yiu and Law, Sze Queenie Pui and Tsang, Yee Jenny Tsun and Lam, Hin Siu and Wang, To Kam and Sin, Kan Olive Shuk and Cheung, Ki Daphne Sze", title="The Effect of the Mediterranean Diet--Integrated Gamified Home-Based Cognitive-Nutritional (GAHOCON) Training Programme for Older People With Cognitive Frailty: Pilot Randomized Controlled Trial", journal="JMIR Rehabil Assist Technol", year="2024", month="Dec", day="13", volume="11", pages="e60155", keywords="cognitive frailty", keywords="gamification", keywords="health education", keywords="Mediterranean diet", keywords="home based", keywords="cognitive training", keywords="older adults", keywords="geriatric", keywords="elderly", keywords="cognitive function", keywords="intervention", keywords="nutritional education", keywords="cognitive impairment", keywords="dementia", abstract="Background: Cognitive frailty is known to be associated with both nutrition and cognitive training. However, effective treatments that engage older adults with cognitive frailty in both the Mediterranean diet and cognitive training are lacking. Objective: This study aims to examine the feasibility and preliminary effects of Gamified Home-Based Cognitive-Nutritional (GAHOCON) on older adults with cognitive frailty, focusing on Mediterranean diet knowledge, adherence to the Mediterranean diet, cognitive function, physical frailty, grip strength, walking speed, memory, and body composition. Methods: This study applied a 2-center, assessor-blinded, 2-parallel-group, noninferiority, randomized controlled trial design. Eligible participants were community-dwelling adults aged 60 years or older, living with cognitive frailty, and exhibiting poor adherence to the Mediterranean diet. Participants were randomly assigned to the intervention or control group in a 1:1 ratio. In the intervention group, participants received 4 weeks of center-based training (health education) followed by 8 weeks of home-based training (GAHOCON). In the control group, participants received only the 4 weeks of center-based training and 8 weeks of self-revision of health educational materials at home. During the intervention period, time spent by the participants and the levels of difficulty completed by them weekly on GAHOCON were measured as markers of feasibility. The outcomes included Mediterranean diet knowledge, adherence to the Mediterranean diet, cognitive function, physical frailty, grip strength, walking speed, memory, and body composition. Data were collected at baseline (T0) and 1 week postintervention (T1). The Wilcoxon signed rank test was used to examine within-group effects for the outcome variables in each group separately. Results: A total of 25 participants were recruited, with 13 allocated to the intervention group and 12 to the control group. The median cumulative minutes spent on GAHOCON training increased from 117 to 926 minutes. The median level of difficulty completed for game 1 increased from level 14 to level 20, while for game 2, it increased from level 2 to level 24. After the completion of the interventions, Mediterranean diet knowledge was retained in the intervention group but significantly decreased in the control group (r=--0.606, P=.04). Significant improvements were observed in the intervention group in Mediterranean diet adherence (r=--0.728, P=.009), cognitive function (r=--0.752, P=.007), physical frailty (r=--0.668, P=.02), and walking speed (r=--0.587, P=.03), but no such improvements were seen in the control group. Conclusions: GAHOCON is feasible in engaging older adults with cognitive frailty to regularly participate in the intervention. Preliminary evidence suggests that it can retain Mediterranean diet knowledge following nutritional education, improve adherence to the Mediterranean diet, and enhance global cognitive function, physical frailty, and walking speed. However, the difficulty of the later levels of game 1 may be too high. Future studies should adjust the difficulty level of game 1. Additionally, trials with larger sample sizes and longer follow-up periods are needed to confirm its effects. Trial Registration: ClinicalTrials.gov NCT05207930; https://clinicaltrials.gov/ct2/show/NCT05207930 ", doi="10.2196/60155", url="https://rehab.jmir.org/2024/1/e60155" } @Article{info:doi/10.2196/47754, author="Fahr, Annina and Kl{\"a}y, Andrina and Coka, S. Larissa and van Hedel, A. Hubertus J.", title="Effectiveness of Game-Based Training of Selective Voluntary Motor Control in Children With Upper Motor Neuron Lesions: Randomized Multiple Baseline Design Study", journal="JMIR Form Res", year="2024", month="Nov", day="18", volume="8", pages="e47754", keywords="neurorehabilitation", keywords="single-case design", keywords="interactive computer play", keywords="cerebral palsy", keywords="surface electromyography", keywords="motor control", keywords="mirror movements", keywords="involuntary movements", abstract="Background: Selective voluntary motor control (SVMC) is the ability to control joint movements independently. Impairments in SVMC can affect functional activities, but only a few interventions directly target SVMC. Therefore, we developed a game-based intervention for children with upper motor neuron lesions to improve SVMC. The intervention trained selective activation of a muscle or joint movement while providing immediate feedback about involuntarily occurring muscle activations or movements in another joint. The intervention was provided in a playful manner with a custom-made game environment and a technology-based interface to capture muscle activation or joint movements. Objective: This study aimed to investigate the effectiveness of this game-based intervention and explore treatment response--related factors in children with impaired SVMC undergoing inpatient neurorehabilitation. Methods: We conducted a single-case research study with a randomized, nonconcurrent, multiple baseline design. The study consisted of a random-length baseline phase where no SVMC-specific intervention was provided and an intervention phase with additional SVMC training. Concurrently in both phases, children attended their individual multimodal rehabilitation program at our clinic, Swiss Children's Rehab. During the intervention phase, participants completed ten 45-minute sessions with our game-based SVMC training. SVMC was measured repeatedly throughout both phases and at the 3-month follow-up with a short custom-made assessment. Results: Eighteen children with reduced SVMC from upper motor neuron lesions participated in the study. The mean age of the children was 12.7 (SD 2.9) years, and they mostly had spastic cerebral palsy. A linear mixed-effects model revealed a significant trend (P<.001) for improved SVMC already in the baseline phase. This trend did not change significantly (P=.15) when the game-based SVMC training was introduced in the intervention phase, suggesting no additional improvements due to the SVMC training. Although we could not find an overall treatment effect, we could explain 89.4\% of the total random variation of the treatment effect by patient and therapy characteristics. Children with spasticity in the trained movement (20.1\%), and those who trained the more affected side (23.5\%) benefited most from the intervention. At the 3-month follow-up, SVMC had deteriorated compared to the end of the intervention but was still better than at the beginning of the study. Conclusions: The regular concomitant rehabilitation program already yielded improvements in SVMC, while the game-based SVMC training showed no additional effects. Although the intervention did not show a group effect, we could identify patient and therapy characteristics that determine who is likely to profit from the intervention. Trial Registration: German Clinical Trials Register DRKS00025184; https://tinyurl.com/msnkek9b ", doi="10.2196/47754", url="https://formative.jmir.org/2024/1/e47754" } @Article{info:doi/10.2196/13723, author="de Vette, Frederiek and Ruiz-Rodriguez, Aurora and Tabak, Monique and Oude Nijeweme-d'Hollosy, Wendy and Hermens, Hermie and Vollenbroek-Hutten, Miriam", title="Developing Game-Based Design for eHealth in Practice: 4-Phase Game Design Process", journal="JMIR Form Res", year="2024", month="Nov", day="8", volume="8", pages="e13723", keywords="game based", keywords="gamification", keywords="game", keywords="eHealth", keywords="telemedicine", keywords="development", keywords="design", keywords="engagement", keywords="game preferences", keywords="older adults", keywords="self-management", keywords="prototyping", keywords="evaluations", keywords="creative", abstract="Background: Games are increasingly used in eHealth as a strategy for user engagement. There is an enormous diversity of end users and objectives targeted by eHealth. Hence, identifying game content that drives and sustains engagement is challenging. More openness in the game design process and motivational strategies could aid researchers and designers of future game-based apps. Objective: This study aims to provide insights into our approach to develop game-based eHealth in practice with a case study (Personalised ICT Supported Services for Independent Living and Active Ageing [PERSSILAA]). PERSSILAA is a self-management platform that aims to counter frailty by offering training modules to older adults in the domains of healthy nutrition and physical and cognitive training to maintain a healthy lifestyle. We elaborate on the entire game design process and show the motivational strategies applied. Methods: We introduce four game design phases in the process toward game-based eHealth: (1) end-user research, (2) conceptualization, (3) creative design, and (4) refinement (ie, prototyping and evaluations). Results: First, 168 participants participated in end-user research, resulting in an overview of their preferences for game content and a set of game design recommendations. We found that conventional games popular among older adults do not necessarily translate well into engaging concepts for eHealth. Recommendations include focusing game concepts on thinking, problem-solving, variation, discovery, and achievement and using high-quality aesthetics. Second, stakeholder sessions with development partners resulted in strategies for long-term engagement using indicators of user performance on the platform's training modules. These performance indicators, for example, completed training sessions or exercises, form the basis for game progression. Third, results from prior phases were used in creative design to create the game ``Stranded!'' The user plays a person who is shipwrecked who must gather parts for a life raft by completing in-game objectives. Finally, iterative prototyping resulted in the final prototype of the game-based app. A total of 35 older adults participated using simulated training modules. End users scored appreciation (74/100), ease of use (73/100), expected effectivity and motivation (62/100), fun and pleasantness of using the app (75/100), and intended future use (66/100), which implies that the app is ready for use by a larger population. Conclusions: The study resulted in a game-based app for which the entire game design process within eHealth was transparently documented and where engagement strategies were based on extensive user research. Our user evaluations indicate that the strategies for long-term engagement led to game content that was perceived as engaging by older adults. As a next step, research is needed on the user experience and actual engagement with the game to support the self-management of older adults, followed by clinical studies on its added value. ", doi="10.2196/13723", url="https://formative.jmir.org/2024/1/e13723" } @Article{info:doi/10.2196/59141, author="Kamnardsiri, Teerawat and Kumfu, Sirintip and Munkhetvit, Peeraya and Boripuntakul, Sirinun and Sungkarat, Somporn", title="Home-Based, Low-Intensity, Gamification-Based, Interactive Physical-Cognitive Training for Older Adults Using the ADDIE Model: Design, Development, and Evaluation of User Experience", journal="JMIR Serious Games", year="2024", month="Oct", day="29", volume="12", pages="e59141", keywords="exergame", keywords="physical-cognitive training", keywords="computer-based interventions", keywords="gamification", keywords="older adults", keywords="instructional design model", keywords="low-intensity", abstract="Background: Declines in physical and cognitive function are natural biological processes, leading to an increased risk of falls. Promising evidence suggests that combined physical-cognitive exercise has beneficial effects in improving both physical and cognitive health. Although moderate-to-high exercise intensity is commonly recommended, it might be impractical for older adults facing physical limitations or contraindications. Thus, low-intensity exercise is a viable option. The main barriers to engaging in exercise in older adults include transportation, time, motivation, and enjoyment. To overcome these challenges, a home-based, gamification-based training system may provide an effective approach to enhance exercise adherence. Objective: This study aimed to develop and evaluate the usability of a low-intensity, gamification-based, interactive physical-cognitive exercise for older adults in a home-based setting. Methods: The prototype of a game-based physical-cognitive exercise was created following the ADDIE model (analysis, design, development, implementation, and evaluation) and assessed for user experience in older adults. A total of 15 older adults engaged in the game-based physical-cognitive exercise at home for 60 minutes per day, 3 days per week, for 4 weeks. The usability of the game-based training system was evaluated using the system usability scale (SUS) after completion of a 4-week training program. As for satisfaction, the 8-item Physical Activity Enjoyment Scale (PACES) questionnaire was used to assess participants' enjoyment level after 1 week and 4 weeks of training. Descriptive statistics were used to illustrate the SUS score. A Wilcoxon signed-rank test was used to compare the PACES scores between the first week and the end of the 4-week period, with significance set at P<.05. Results: As for experts' consensus, the game-based training consisted of 3 games: Ocean Diver, Road Runner, and Moving and Memorizing. The games had 3 levels of difficulty: beginner, intermediate, and advanced. A computer vision--based system was selected as the delivery platform for a home setting. The total SUS score for all participants was mean 87.22 (SD 5.76), indicating the user's perception of the usability of a system ranging from good to excellent. At the end of the 4-week training, the total PACES score was significantly greater than the first week, suggesting an improvement in enjoyment (first week: mean 44.93, SD 3.99 vs fourth week: mean 50.53, SD 4.70; P=.001). Conclusions: The prototype of low-intensity, gamification-based, interactive physical-cognitive training was designed and developed using the ADDIE model, which included both experts and end users in the process. The findings showed that the exergame prototype was a usable and practical approach for a home-based setting, enhancing older adults' enjoyment and motivation. Further research is warranted to determine the effectiveness of such gamification-based training in promoting physical and cognitive functions. ", doi="10.2196/59141", url="https://games.jmir.org/2024/1/e59141" } @Article{info:doi/10.2196/52563, author="Lo, Man Hermione Hin and Ng, Marques and Fong, Hugo Pak Yiu and Lai, Ki Harmony Hoi and Wang, Bo and Wong, Yeung-shan Samuel and Sit, Shan Regina Wing", title="Examining the Feasibility, Acceptability, and Preliminary Efficacy of an Immersive Virtual Reality--Assisted Lower Limb Strength Training for Knee Osteoarthritis: Mixed Methods Pilot Randomized Controlled Trial", journal="JMIR Serious Games", year="2024", month="Sep", day="27", volume="12", pages="e52563", keywords="virtual reality", keywords="VR", keywords="immersive", keywords="knee", keywords="joint", keywords="arthritis", keywords="arthritic", keywords="osteoarthritis", keywords="knee osteoarthritis", keywords="gerontology", keywords="geriatric", keywords="older adult", keywords="elder", keywords="elderly", keywords="older person", keywords="older people", keywords="aging", keywords="pain", keywords="function", keywords="acceptability", keywords="user experience", keywords="RCT", keywords="randomized", keywords="controlled trial", keywords="limb", keywords="strength", keywords="muscle", keywords="muscular", keywords="physiotherapy", abstract="Background: Knee osteoarthritis prevalently causes significant pain, activity limitations, psychological distress, and reduced quality of life. Despite lower limb strength training being a core treatment for knee osteoarthritis, adherence remains a challenge, prompting the exploration of virtual reality (VR) to improve exercise compliance. Recent research suggests the potential of VR in providing enhanced pain management and functional outcomes for knee osteoarthritis, necessitating further exploration of immersive VR technology. Objective: We aimed to study the feasibility, acceptability, and preliminary efficacy of an immersive VR-assisted lower limb strength training for knee osteoarthritis (VRiKnee). Methods: A convergent, parallel, mixed methods study was conducted in 30 participants with knee osteoarthritis. After 1:1 randomization, the VRiKnee group (n=15) was assigned to perform repetitive concentric quadriceps and isometric vastus medialis oblique exercise in an immersive environment using a head-mounted display for 12 weeks. The control group (n=15) completed the same exercises without VRiKnee. VRiKnee participants were interviewed at week 12 to study VRiKnee acceptability and user experience. Quantitative data included feasibility outcomes such as recruitment, dropout, and exercise adherence rates, and effectiveness outcomes such as the numeric rating scale, the Western Ontario and McMaster Universities Osteoarthritis Index (100 points) pain and function subscales, and objective physical activity measured by metabolic equivalents of task using an ActivPAL accelerometer. Qualitative data were analyzed by thematic analysis, followed by integration with quantitative data using joint displays. Results: The recruitment rate was 100\% (N=30), with enrollment of 30 participants in 7.57 weeks. The median age was 63.5 (IQR 61.8?66.3) years, with 76\% (n=23) being female. The response rates were 80\% and 93\% for the VRiKnee and control groups. Dropout rates were 13\% for VRiKnee and 7\% for the control group. Median exercise adherence was 77\% (IQR 37-104\%) for VRiKnee and 62\% (IQR 40-166\%) for the control group, respectively, with adherence reduction over this study's period and no significant intergroup differences (P=.82). No statistically significant differences were observed in primary and secondary outcomes, though positive trends were observed in pain and stiffness. Cybersickness was reported by 5 (33\%) participants in the VRiKnee group. In the qualitative analysis, 4 themes, 11 subthemes, and 16 quotes were generated, identifying facilitators and barriers with practical suggestions to enhance the usability of VRiKnee. Conclusions: VRiKnee demonstrated feasibility, acceptability, and potential efficacy in managing knee osteoarthritis. Future trials of larger sample sizes and better VR designs will confirm its role in clinical practice. Trial Registration: Chinese Clinical Trial Registry CHiCTR2100046313; https://www.chictr.org.cn/showprojEN.html?proj=125404 ", doi="10.2196/52563", url="https://games.jmir.org/2024/1/e52563" } @Article{info:doi/10.2196/54082, author="Cederved, Catarina and Ljungman, Gustaf and Back, Jon and {\AA}ngstr{\"o}m-Br{\"a}nnstr{\"o}m, Charlotte and Engvall, Gunn", title="Acceptability of a Serious Game About Proton Radiotherapy Designed for Children Aged 5 to 14 Years and Its Potential Impact on Perceived Anxiety: Feasibility and Randomized Controlled Pilot Trial", journal="JMIR Serious Games", year="2024", month="Sep", day="23", volume="12", pages="e54082", keywords="anxiety", keywords="feasibility", keywords="acceptability", keywords="pediatric oncology", keywords="psychological preparation", keywords="proton radiotherapy", keywords="serious game", keywords="games", keywords="cancer", abstract="Background: Children who are going to undergo radiotherapy have displayed fear and anxiety. Therefore, a web-based serious game was developed as a psychological preparation to investigate if it could affect anxiety levels. In an earlier stage, children with experience of radiotherapy had been part of the developmental process. Objective: The study aimed to investigate the feasibility in terms of reach, usability, and acceptability of a serious game about proton radiotherapy and to pilot that it did not increase anxiety levels in children aged 5 to 14 years undergoing radiotherapy. Methods: The design was a randomized controlled pilot trial with predefined feasibility criteria. In total, 28 children were assessed for eligibility, and 23 met the inclusion criteria. They were consecutively randomized into 1 of 2 study arms. One child was excluded after randomization. If randomized into arm 1, the children received the intervention before treatment started. Children in arm 2 were treated as controls. Questionnaires with fixed answers were used to assess anxiety levels (an adapted version of the State-Trait Anxiety Inventory for Children) and experiences of gameplay (an adapted version of Player Experience of Need Satisfaction [PENS]). The children were asked to answer questionnaires at 5 different measurement occasions during their radiotherapy treatment. Results: In arm 1, age ranged from 5 to 13 (mean 8.4, SD 2.4) years. In arm 2, age ranged from 5 to 11 (mean 7.6, SD 2.3) years. The sample consisted of 15 girls and 7 boys. The feasibility criterion that the children should play the game for 20 minutes or more was not met. Mean playtime for children in arm 1 was 32.1 (SD 23.8) minutes, where 18 children had played for at least 15 minutes. The criterion that 70\% (n=16) or more of the participants should return all of the questionnaires was not met; however, more than 73\% (n=16) returned the PENS questionnaires. The State-Trait Anxiety Inventory for Children was returned by 73\% (n=16) on day 0, 77\% (n=17) on day 1, 82\% (n=18) on day 3, 82\% (n=18) on day 6, and 86\% (n=19) on day 15. Conclusions: All feasibility criteria set for the study were not met, suggesting that adaptions need to be made if a future study is to be undertaken. Further, the analysis revealed that there was no indication that playing increased the children's self-reported anxiety. The PENS questionnaire adapted for children showed promising results regarding player satisfaction when using the serious game. When studying children with severe conditions and young age, 5 measurement occasions seemed to be too many. Measuring both player satisfaction or experience and knowledge transfer would be preferable in future studies. Trial Registration: ClinicalTrials.gov NCT04728555; https://clinicaltrials.gov/study/NCT04728555 ", doi="10.2196/54082", url="https://games.jmir.org/2024/1/e54082" } @Article{info:doi/10.2196/55613, author="Lopes, Henrique and Baptista-Leite, Ricardo and Hermenegildo, Catarina and Atun, Rifat", title="Digital Gamification Tool (Let's Control Flu) to Increase Vaccination Coverage Rates: Proposal for Algorithm Development", journal="JMIR Res Protoc", year="2024", month="Sep", day="10", volume="13", pages="e55613", keywords="influenza", keywords="gamification", keywords="public health policies", keywords="vaccination coverage rates", keywords="health promotion", abstract="Background: Influenza represents a critical public health challenge, disproportionately affecting at-risk populations, including older adults and those with chronic conditions, often compounded by socioeconomic factors. Innovative strategies, such as gamification, are essential for augmenting risk communication and community engagement efforts to address this threat. Objective: This study aims to introduce the ``Let's Control Flu'' (LCF) tool, a gamified, interactive platform aimed at simulating the impact of various public health policies (PHPs) on influenza vaccination coverage rates and health outcomes. The tool aligns with the World Health Organization's goal of achieving a 75\% influenza vaccination rate by 2030, facilitating strategic decision-making to enhance vaccination uptake. Methods: The LCF tool integrates a selection of 13 PHPs from an initial set proposed in another study, targeting specific population groups to evaluate 7 key health outcomes. A prioritization mechanism accounts for societal resistance and the synergistic effects of PHPs, projecting the potential policy impacts from 2022 to 2031. This methodology enables users to assess how PHPs could influence public health strategies within distinct target groups. Results: The LCF project began in February 2021 and is scheduled to end in December 2024. The model creation phase and its application to the pilot country, Sweden, took place between May 2021 and May 2023, with subsequent application to other European countries. The pilot phase demonstrated the tool's potential, indicating a promising increase in the national influenza vaccination coverage rate, with uniform improvements across all targeted demographic groups. These initial findings highlight the tool's capacity to model the effects of PHPs on improving vaccination rates and mitigating the health impact of influenza. Conclusions: By incorporating gamification into the analysis of PHPs, the LCF tool offers an innovative and accessible approach to supporting health decision makers and patient advocacy groups. It enhances the comprehension of policy impacts, promoting more effective influenza prevention and control strategies. This paper underscores the critical need for adaptable and engaging tools in PHP planning and implementation. International Registered Report Identifier (IRRID): RR1-10.2196/55613 ", doi="10.2196/55613", url="https://www.researchprotocols.org/2024/1/e55613", url="http://www.ncbi.nlm.nih.gov/pubmed/39255031" } @Article{info:doi/10.2196/54193, author="Bressler, Michael and Merk, Joachim and Gohlke, Tanja and Kayali, Fares and Daigeler, Adrien and Kolbenschlag, Jonas and Prahm, Cosima", title="A Virtual Reality Serious Game for the Rehabilitation of Hand and Finger Function: Iterative Development and Suitability Study", journal="JMIR Serious Games", year="2024", month="Aug", day="27", volume="12", pages="e54193", keywords="video games", keywords="virtual reality", keywords="exercise therapy", keywords="physical therapy", keywords="hand rehabilitation", keywords="finger rehabilitation", abstract="Background: Restoring hand and finger function after a traumatic hand injury necessitates a regimen of consistent and conscientious exercise. However, motivation frequently wanes due to unchallenging repetitive tasks or discomfort, causing exercises to be performed carelessly or avoided completely. Introducing gamification to these repetitive tasks can make them more appealing to patients, ultimately increasing their motivation to exercise consistently. Objective: This study aims to iteratively develop a serious virtual reality game for hand and finger rehabilitation within an appealing and engaging digital environment, encouraging patient motivation for at least 2 weeks of continuous therapy. Methods: The development process comprised 3 distinct stages, each of which was subject to evaluation. Initially, a prototype was created to encompass the game's core functionalities, which was assessed by 18 healthy participants and 7 patients with impaired hand function. Subsequently, version 1 of the game was developed and evaluated with 20 patients who were divided into an investigation group and a control group. On the basis of these findings, version 2 was developed and evaluated with 20 patients who were divided into an investigation group and a control group. Motivation was assessed using the Intrinsic Motivation Inventory (IMI), while the application's quality was rated using the Mobile Application Rating Scale and the System Usability Scale. User feedback was gathered using semistructured interviews. Results: The prototype evaluation confirmed the acceptance and feasibility of the game design. Version 1 significantly increased motivation in 2 IMI subscales, effort (P<.001) and usefulness (P=.02). In version 2, a significant increase in daily performed exercises was achieved (P=.008) compared to version 1, with significantly higher motivation in the IMI subscale effort (P=.02). High Mobile Application Rating Scale scores were obtained for both versions 1 and 2, with version 2 scoring 86.9 on the System Usability Scale, indicating excellent acceptability. User feedback provided by the semistructured interviews was instrumental in the iterative development regarding improvements and the expansion of the playable content. Conclusions: This study presented a virtual reality serious game designed for hand and finger rehabilitation. The game was well received and provided an environment that effectively motivated the users. The iterative development process incorporated user feedback, confirming the game's ease of use and feasibility even for patients with severely limited hand function. ", doi="10.2196/54193", url="https://games.jmir.org/2024/1/e54193", url="http://www.ncbi.nlm.nih.gov/pubmed/39190432" } @Article{info:doi/10.2196/54684, author="Goodwin, Shelby and Nastasi, A. Jessica and Newman, T. Schyler and Rapoza, Darion and Raiff, R. Bethany", title="Feasibility and Acceptability of a Mobile Game to Support Smoking Cessation: Repeated Measures Study", journal="JMIR Serious Games", year="2024", month="Aug", day="21", volume="12", pages="e54684", keywords="mHealth", keywords="mobile health", keywords="smoking cessation", keywords="video game intervention", keywords="mobile phone", abstract="Background: Approximately half of smokers attempt to quit, but 90\% of these attempts fail. Video game--based interventions have the potential to address common barriers to evidence-based smoking cessation treatment, including high cost, lack of health care access, and low engagement. Objective: The purpose of this study was to evaluate the feasibility and acceptability of a video game--based smoking cessation intervention called Inspired and its impact on the 7-day smoking point prevalence at the 30-day follow-up. Methods: US adults (n=48) were recruited via the web to use Inspired on their smartphones for 7 weeks. The object of the game was to defend a healing tree against attackers. Levels of the game were unlocked twice daily when participants self-reported the number of cigarettes they smoked since the previous entry. Completion of the levels awarded players in-game currency, which could strengthen in-game abilities. Participants received additional in-game rewards to aid gameplay by submitting either smoking self-reports only or self-reports indicating abstinence, determined through random assignment. In addition, participants completed a web-based survey at intake, week 4, week 7, and the 30-day follow-up. Results: Of the 48 participants, who had an average age of 39.8 (SD 10.7) years, 27 (56\%) were female, 4 (8\%) Hispanic, 37 (77\%) White, and 27 (56\%) employed; 26 (54\%) earned